Tucker, Wilford 93V
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
e r o iu &, TU Gk evL I if el,br'
r>`" Date of Death Age If Veteran of U.S. Armed F rces,
) z./2-7 J/to 61 Z War or Dates ,J/K-
Place of Death I Hospital, Institution or /f
jj City(Tov r Village Q U&�'.oS t o (street Ad rd eis S t-/ /4 U/.7o,.)
Manner of Death LAI.Natural Cause El Ajkident (l Homicide E Suicide 7 Undetermined Pending
tg Circumstances Investigation
w Medical Certifier Name ?? Title
CI .) L U t l//` G„) /-/, �.
Address �l / r
3 7 to 2 / I .J �r_ W B-rwL�N.;8 un-4 ./t/ l 2„Pcp-,i—
Death Certificate Filed/� I Di ipt NJgnber Fte is r Number
'< City, 1 ow r Village 061'iv'.s g 01,�/ ( ( r
Burial Date - j / Cemetery o �/
Q EntombmentI I Z/Z�"/6, t,J 4r L i
Address
,I,
;' ' Cremation Q uAie b�_ � : Q Ube,.).f W27 4J
— Removal I Date Place RemovedFrk /
and/or Held
— and/or Address
8Hold
Date Point of
E Transportation Shipment
a , by Common Destination
Carrier
1-1
Li Disinterment Date Cemetery Address
gi
M Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home '.�1C_t- L;1 - \ \--ND f1 t-- C 11 C
Address r.
k 1 t- e-k—Cl i C - =-ter- �v e-A-1- _; 1 t tN tZ c q
Name of Funeral Firm Making Disposition or to Whom
i ; Remains are Shipped, If Other than Above
Address
it
LEI
il` Permission is hereby granted to dispose of the human r ains described bo e as indicated.
Date Issued\c�-,a�I l(PRegistrar of Vital Statistics l -i
(signature)
District Number c Place C 0, , 0- C/U._fast..4--).c10
I certify that the remains of the decedent identified above were disposed of in ac ordance ith this permit on:
lit Date of Disposition I Z13l jg Place of Disposition i2 in e i)jam.,) ��Q. ('
2 ( (address) /
0
E (section) (lot number) (grave number)
O.
Name of Sexton o in Charge of Premises /ram✓! rY� e
Z (please print)
44
Signature 6 /l Title C- -- ''L 'r ,e
(over)
DOH-1555 (02/2004)